By Lilian Anekwe
Shadow health minister Mark Simmonds tells Pulse why private providers are not a bad thing in the NHS and details the Conservative’s plans for out-of-hours care and the QOF.
What will the big issues be in the run-up to the election?
The big challenge for us is to convince the electorate that the NHS will be the number one priority for an incoming Conservative Government. Which is why we’ve said that we will ringfence the NHS budget, it won’t be subject to the cuts of that other departments will be. Even more than that, we’ve said we’re going to increase in real terms the investment in the NHS in the lifetime of the next Parliament. So it’s a significant commitment from the Conservative party to the NHA. That’s as relevant to primary care as it is to all the rest of the health service.
How will Tories repair the fractured relationship between GPs and ministers?
Any changes to primary care and general practice we want to make in consultation with GPs and their representatives, rather than just impost them from the centre without consultation, which has happened all too often in the past.
The second and most critical thing is we want to give GPs and consortia of GP practices hard budgets so that they can lead commissioning and purchase services on behalf of their patients, and on behalf of their communities, that accurately reflect the needs of those communities. We wouldn’t be, for example, imposing from the centre one Darzi centre for every single PCT irrespective of whether its wanted, needed, or the best way to spend resources. The bottom-up solution is far better. By giving consortia the lead in commissioning services, not only will they be able to respond to the needs of their patients better but they will also be able to innovate on behalf of the communities they are looking after, which they either can’t or find very difficult to do at the moment. Which is why PBC has run into the sand. Most GPs seem to be very enthused and excited about this policy.
We will offer real budgets, real cash. That’s the big difference between PBC and our proposals of GP-led commissioning. Obviously there will be others involved in the commissioning process, but we think because GPs are the gatekeepers to the NHS – 80-90% of the interaction a patient has with the NHS is through primary care and GPs – they are in the best position to know and respond and reflect the need of their particular patient groups.
While there is some good commissioning taking place in PCTs its extremely patchy, and if consortia want to link into the commissioning expertise that exists in the PCT they’ll be able to do that. We won’t stop them. But they may want to bring in commissioning expertise from elsewhere. So we hope to be able to create a place where the best and most appropriate commissioners come in to commission on behalf of patients.
What other areas can GPs commission?
The biggest and most significant mistake of the 2004 contract was to the Government allowing GPs to completely opt out of any involvement with OOH care, both providing and commissioning. We think that GPs should be involved in the commissioning of OOH care, not a return to pre-2004 days. So they will have the ability to be involved in structuring the service, and where they choose, to provide it. But we are not proposing a return to the pre-2004 status. So GPs will not have a legal responsibility, but certainly they should have an involvement in the structure of the service and where they have an involvement in structuring the service, the service is far better and far more reflective of the needs of the patient than where they’re not involved.
We think GPs should be responsible for commissioning most services. Particular is relation to OOH, perhaps they should be involved in commissioning urgent care as well, or commissioning urgent care from other providers – walk-in centres, for example. So you get continuity of commissioning which at the moment is very fractured in some places. Now, there will be services that have to be commissioned outside the remit of the consortium of GPs, either at primary care level or higher up. Rarer cancers is the best example, where regional or even national commissioning structures are more efficient.
How can the GP contract be used to drive efficiency?
There are three things to say. Firstly, of course we’ve got to look at efficiencies. Making the use of taxpayers money deliver the maximum patient outcome that we possibly can. The second thing is We want to make sure that the QOF aspect of GPs’ remuneration is focused more on clinical outcomes than it is on processes. So we are monitoring very carefully what NICE are doing with reference to the QOF and we want to make sure that it’s delivering clinical outcomes and GPs are rewarded for those outcomes much more so than they are at the moment through the QOF.
The third aspect is to make sure we work with GPs to ensure that we’re not going to go through an imposed through the centre, which is what the current Government does and is a big mistake. It’s quite an achievement to annoy GPs and make them feel unloved and not responsible in the way they have. GPs are the integral part of access to the NHS. Which is why they should be given more responsibility, but the consultation is an important part of it.
Will the Tories look at the GP contract?
Well, we’re going to have to renegotiate the contract because we’re going to have to give GPs a more clinically-focused QOF. We’re also going to have to renegotiate the contract to make sure it takes into consideration the fact that GPs are going to be leading on commissioning and that’s an additional responsibility. I’m not going to put on the record confidential discussions that we’ve had, but we’re in regular contact with the BMA, Andrew Lansley and I have met the negotiators, we’re in regular contact with the RCGP. Any renegotiation of the contract is an integral part of that.
What might the local negotiations look like?
The best way is to distinguish between GP-led commissioning and what happened under fundholding, because there are distinct differences. What we’re not going to allow is, and what happened under fundholding, is that when GPs drove efficiency savings they were allowed to put in their pocket the difference. We are not going to allow that. the vast bulk of that will have to be reinvested back into frontline care. The second difference is that GPs will not automatically be allowed to commission services from themselves as providers. There will be an ongoing role for the PCT to ensure that the most efficient and effective provider is actually providing the service. Now that might be the GP; it might be the pharmacist, it might be a third, voluntary, charitable organisation or it might be A N Other. That will depend on individual locality and circumstance. That’s quite a distinct difference. But commissioning will be difference in Birmingham than in rural Lincolnshire because of the obvious difference in the needs of those communities.
How hard will the clinical outcomes in the QOF be?
We don’t intend to impose from the centre a strict set of outcome measures in the way the current Government has imposed a strict target measure. That is not what we’re about. The outcomes will have to be in conjunction with clinicians, and I suspect interim outcome measures. So for example, where you’re trying to measure prevention and public health there’s quite a significant lag time, therefore there will have to be interim measurements to make sure that people are not being unfairly penalised – particularly those working in more challenging areas, with socioeconomic differences and widening health inequalities.
There will have to be a national framework, but we want to negotiate what clinicians themselves feel are the fairest and most appropriate outcomes to measure the impact on patients.
How much of a role should private providers be given?
Our policy is very clear: any willing provider. I don’t see why we should get hung up on the delivery mechanism. What’s important is that patient outcomes and making patients better. And I’m slightly perplexed by some GPs saying these things, because they’re independent providers anyway. So the logical extension of this argument is that GPs should become part of the state structure, which is not what we want and certainly the GPs I talk to don’t want that.
I think that any willing provider – as long as they meet the safety standards, national frameworks – I don’t think we should get too hung up on the delivery mechanisms as long as they are delivering the patient outcomes that are important.
I don’t but the argument that they are a threat or only interested in profits at all. I think that you’ve got to have an element of competition in the system, as it tends to drive efficiencies, as long as you have comparable and benchmarkable information to inform patient choice. That way, patients can see which provider is providing the best patient outcomes and make a choice. Some people will want to go to provider X, others provider Y, but at the moment people can’t make that choice. And that’s just as true in primary care as it is in the acute sector.
There’s an enormous information gap and it’s the missing link in driving a really patient-focused NHS. We have to find ways of providing accurate, easily-communicable information to patients to drive patient choice.
NHS Choices is state run-provision, it’s pretty impenetrable, there’s no patient-centric information on it. We want to move beyond that and wee don’t see why the state should provide all the information to patients. There should be a plethora of information, a marketplace of providers giving this information to patients, who will then have the ability to pick and choose where they want tor receive information from. If a patient moves to my constituency in Lincolnshire at the moment its very difficult for them to access information about general practices across Lincolnshire. We need to find ways of getting patients to feed information back in, and then that information can be put into the public domain so that patients can make the comparison between one GP practice and another. They type of service, and the level of service they provide. If the money follows the patient, and we’ve said it should, then that will give much more patient choice to go where they think they are going to get the service that is most appropriate for them.
What kinds of information will you provide to patients?
18’48 The NHS IC should compile more data on general practice that’s relevant to patients.
Benchmark it, make sure it’s comparable. Then providers should present that in a way that’s relevant to patients.
Is the information provided by balanced scorecards valuable?
Balanced scorecards are more about processes than outcomes and we need to make it more focused on patient outcomes. There’s a lot of data that’s collected by PCTs that has to be repackaged in different ways at enormous administrative cost. So we do need to look at streamlining the information and data that’s being collected. It’s got to be relevant to patient care otherwise there’s no point in collecting it. We do need to look at balanced scorecards to make sure it reflects what GPs are achieving in terms of outcomes for patients.
Which public health policies would the Tories consider scrapping?
We think there needs to be a much greater emphasis on public health and prevention, which is why we will ringfence public health budgets. There’s no clinical evidence to support whole population screening at all. Inevitably we’re going to have to focus the resources where they will have the maximum impact. We are going to have to look and monitor the vascular screening programme to make sure that they are providing the outcomes that we all hope that we will. It’s not something we’ve said we’re going to scrap but we are quite keen to monitor and evaluate it as it goes forward as it’s very patchy.
Where can GPs make efficiency savings?
Two things: one is trying to ensure that the focus of GPs is on the patient outcomes, and secondly, moving away from the processes and targets that drive the system at the moment. We feel that that in itself will drive efficiencies, which will create opportunities to realign and refocus resources. Let me give a couple of examples: we want to cut a third of administration in the NHS and put that into patient care. The other area is the quangocracy that exists in the NHS. We want to streamline or merge quangos, and where they are not providing patient outcomes, got rid of altogether.
Mark Simmonds MP